CARE HOME ADULTS 18-65
28 Newland Street 28 Newland Street Crumpsall Manchester M8 5RY Lead Inspector
Steve O`Connor Unannounced Inspection 17 May 2007 10:30 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 28 Newland Street Address 28 Newland Street Crumpsall Manchester M8 5RY 0161 740 9785 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southfields Care Homes Limited T/A The Regard Partnership Limited Post Vacant Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th December 2006 Brief Description of the Service: The home is a terraced house situated in the Crumpsall area of Manchester with easy access to local facilities e.g. shops, services, and places of worship, pubs and local transport. The home provides accommodation for 2 persons with mental health problems. Fees are based on individuals’ level of support needs. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was last inspected in December 2006. During the unannounced inspection site visit to the home on the 17 may 2006, time was spent talking with people who live at the home, talking to and observing how staff work with people and the recently appointed manager. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. Further documentation was examined on the 18 May 2006 at the manager’s office based at another of the registered providers care homes. The inspection report of December 2006 highlighted a number of areas that the home needed to work on and improve. The home had addressed some of the changes needed from the last inspection report. However, a number still remained and had to be repeated again in this report. This key inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do with the home. What the service does well: The home continues to understand that it is important to find out how good the service they provide actually is. The company that owns the home carries out regular checks and their own inspections to find out how well the home is doing and how it can improve. The manager has recently introduced a new way for people and staff to spend time together, on a regular and ongoing basis, to sit down and talk about how the person feels about the service and to raise any concerns or problems they have. An area that the home continues to take seriously was maintaining people’s general and mental health. The home supported people to access local general health services such as the G.P. dentist, chiropodists, etc. The home had made sure that people received support from specialist mental healthcare services and had worked with those services to monitor and maintain people’s health. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
The inspection report highlighted a number of areas that the home was required to take action. These include the following issues, which had been raised in the previous inspection report and have not been adequately addressed. Previous inspection reports have highlighted that the house requires investment in refurbishment and decoration to raise its standard. Areas identified as needing improvement included the kitchen and bathroom areas. The company that manages the home (Southfields Care Homes Limited T/A The Regard Partnership Limited) had been requested in two inspection reports to set out a plan for how they are going to raise the standards of the home but have not provided the CSCI with any information on how or when they are going to achieve this. The issue of providing staff with the required training, skills and knowledge had been raised through previous inspection reports and the last report required
28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 7 the home to provide the CSCI with evidence that they were providing this training. No information was received within the timescale given. The last two inspection reports had also identified the need for the staff team to undertake further medication training due to the errors found in the medication administration system. There was no evidence that the home had provided staff with this training and this was emphasised through the concerns found in how the home were managing peoples’ medication. The inspection found errors despite these issues being raised in the last inspection report and the home’s Improvement Plan, of November 2006, stating that they would provide a safe and accurate medication administration system. The previous inspection report highlighted that the home were using a high level of agency staff to provide the support people required. The manager at the time stated that more staff were being recruited and this would reduce the reliance on agency staff. It was found that the home still needed to cover at least four full shifts every week to provide the support that people needed. It was also found that even though the people who lived at the home needed support in the community the home only provided one member of staff after 5:00 pm. This limited peoples’ access to community social and leisure activities to when the home could provide the staff support rather than when people wanted. The home had a clear policy and procedure for helping people to manage their personal finances. The recording system had been seen during previous inspection site visits and found to be clear and accurate. However, it was found on this site visit that the previous manager had introduced their own recording system and that this contained errors and did not reflect the home’s own procedures. It could not be explained why this change had not been picked up through the home’s quality assurance system and was still being used seven weeks after the appointment of the new manager. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems were in place to make sure that peoples’ needs are assessed prior to living at the home. EVIDENCE: There had been no new admissions to the home since the previous inspection. The home had a referral process for when there is a vacancy. This could be from a purchasing authority or internally from another of the main company’s homes and services. Pre-admission assessment information from the purchasing authority had been made available prior to people coming to live at the home. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the whole, the home does understand and provide the support and help that people need on a day-to-day basis. However, this is not always reflected through the care planning or risk assessment systems, which means that the home cannot clearly evidence that peoples holistic needs and choices are being met. EVIDENCE: The previous inspection report highlighted that people’s care plans should fully identify peoples’ goals and support needs. Evidence was seen that the care plans had been reviewed and updated and contained more detailed information on what support people needed. It also included more information about the people themselves including details of their likes and dislikes and activities they like to participate in. The previous report also recommended that the home develop and implement a more person centred planning approach to how people identify their own
28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 11 needs, goals and the help they need to achieve them. The recommendation regarding person centred care planning was reiterated. The manager stated that as the care plans had only recently been updated they had not yet implemented a formal care planning review system to reflect the ongoing and changing needs of people living at the home. They had introduced a ‘Keyworker’ system where a named member of staff would work more closely with a person to regularly review the support they receive and to raise any concerns or changes in their needs. The home must ensure that they evidence clearly how peoples support and needs are being met and changes are clearly reflected and understood so that people receive the support they need. The previous inspection report required the home to review its risk assessment systems to ensure that the support people needed to take risks were supported and managed correctly. Examples of risk assessments and behavioural guidance were seen that had been reviewed and updated to reflect current practice. These included guidance in supporting a person’s behaviour and rituals. The new guidance showed that the home were now looking to support the person rather than to restrict or stop them carrying out behaviours that are important to the person. To prove that staff had read and understood the new guidance they were required to sign the report. The manager was asked about how they could show that agency staff had read and understood the guidance. It is recommended that all agency staff who have not worked with people before sign the guidance to show that they have read and understood it. The manager acknowledged that not all the risk assessments had been rewritten and guidance updated but they were working on these at the current time. Therefore, the requirement was reiterated. Previous inspection reports had found that the home had placed some restrictions on people’s choices and access to parts of the home. This had been explained as responses to incidents and behaviours that could place people at harm. The home was required to ensure that all restrictions of choice, movement and access within the home had been implemented as a result of a risk assessment. The manager confirmed that the practice of locking certain rooms in the house had now stopped. During the site visit the interaction between staff and a person living at the home was seen when staff were trying to offer the person a range of choices of leisure activities that the person had said that they enjoyed. The interaction was positive and respectful and gave the person the opportunity to decide for themselves what they wanted to do.
28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are on the whole supported to make their own choices and decisions about the lifestyle they lead and the activities they want to participate in within the limits of the available staff support. EVIDENCE: People living at the home receive support on a 1:1 basis at set times during the week. The aim of this support is to enable people to take part in activities that are meaningful and useful for them. This could be social and leisure activities or skills development, such as education or employment. The issue of people living at the home having access to meaningful activities had been raised through previous reports and other information provided to the CSCI. The manager acknowledged that the 1:1 supported ended at 5:00pm when there was one member of staff on duty. As people required support to access
28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 13 the community the staffing arrangement meant that, unless people went out together, they could not participate in social and leisure events in the evening. The issue of staffing is further addressed in the Staffing section of the report. The manager confirmed that they had developed a ‘keyworker’ role for staff so that they would spend more time with people to find out what activities they enjoyed. Evidence was seen that a range of ideas had been suggested and staff were finding out information on how people could access these activities. During the inspection site visit people were talking to staff about the leisure and social activities they wanted to take part in. People were encouraged and supported to maintain and develop links with their families and friends based on people’s own wishes. An example was seen where a person’s wishes in respect to contact with family had been supported and action taken to make sure the contact was as the person wanted. People still mostly set their own routine in terms of the activities that they participate in. However, the staffing arrangements did play a large part in determining those routines as beyond 5:00pm there was one member of staff on duty and so individual activities had to have been completed by then. Meals are determined by people themselves and their own personal choices and preferences. The home does provide support and guidance regarding healthy diet choices. Mealtimes are flexible and are taken when it suits people and not the home. There was a reasonable stock of food in the home. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s personal and healthcare needs were known and they were supported to maintain this. However, not all the systems for supporting peoples’ health and wellbeing are fully safe or reflected what support people actually need. EVIDENCE: The previous inspection report highlighted that there was issues around a person’s personal care that was not reflected in the person’s care plan. The manager stated that peoples’ personal care and healthcare needs were in the process of being reassessed and care plans would reflect more accurately the level of support that people actually needed. The home must ensure that peoples’ personal and healthcare cares are clearly identified, recorded and reflected through the care planning process to make sure that they receive the support that they need. Information in relation to people’s general healthcare needs was recorded in the individual care plans. The home supported people to access healthcare appointments.
28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 15 The previous two inspection reports highlighted a number of concerns with the medication administration system. They included staff needing to receive suitable medication training to ensure that they are competent, that medication recording was accurate and that the home implemented an auditing and monitoring system. The medication administration records were seen and found that the administered medication had been accurately recorded. Medication that was prescribed ‘as required’ (PRN) had separate administrating guidance. One person’s medication regime contained a mixture of on going and PRN medication that related to their emotional health and behaviour. The guidance on administering was unclear as to what medication should be given and what the triggers were for administering which medication. It is recommended that the guidance for administering PRN medication is reviewed to include greater information and detail in relation to when to use the relevant medication. The person had not had their medication regime assessed for some time. It is recommended that people’s medication regime is regularly reviewed to ensure they are still meeting the person’s needs. The manager acknowledged that she had yet to implement an auditing and monitoring system but this was a priority for her. Samples of staff training records were seen and an example was seen where there was no evidence that the staff member had undertaken any medication training. The previous requirements relating to training and auditing were reiterated. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems were in place to protect people but not all of these systems were being followed which did not ensure that people are safe from financial abuse. EVIDENCE: The manager had introduced a ‘keyworker’ system where staff would spend time with people and discuss any concerns and worries they had. Evidence was seen of when a person raised concerns about the environment of the home and this was recorded, and actions set to resolve the concerns. The home had a complaint policy and procedure and a copy of the MultiAgency Protection of Vulnerable Adults. Staff would receive training with regards the protection of vulnerable adults through the Induction Programme and if they had undertaken the NVQ Level 2 qualification. The manager was able to describe the procedures for responding to concerns around adult protection issues. The home has a clear policy and procedure for managing peoples’ personal finances. On previous inspection visits these have been sampled and checked for accuracy. During the inspection visit it was found that the previous manager had decided not to use the set recording procedures and had implemented their own records. These did not accurately account for all monies coming into the home
28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 17 and given to people. The current manager did not know why the set procedures had not been followed but stated that they would reinstate the normal recording procedures immediately. The home must ensure that they have the systems in place to accurately record and audit peoples’ personal finances in accordance to their own policy and procedures to protect people from possible abuse. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The premises were generally clean but did not provide a homely, comfortable or safe environment for people to live. EVIDENCE: The last four inspection reports have highlighted the poor standard of the maintenance, decoration, fixtures and fittings of the home. The company that manages the home (Southfields Care Homes Limited T/A The Regard Partnership Limited) had previously provided the CSCI with plans for the refurbishment of the home. This had not been fully actioned as the house was still poorly decorated, fixtures and fittings were of a poor quality and a number of areas needed repair and replacement. The previous two inspection reports have required the home to undertake an audit of all the work required and to provide the CSCI with an action plan and
28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 19 timescales. This was never provided to the CSCI and so the requirement was reiterated. During a tour of the premises the following areas of concern were noted. The kitchen units looked worn and dated. Some of the work surfaces were cracked and broken and needed replacing. The bathroom was in need of decoration. The bathroom sealant was in a bad condition and needed replacing. The shower did not work and needed repairing. The issue of the shower not working had been raised in previous inspection reports and this had still not been addressed. People stated that they preferred to take showers. The previous inspection report highlighted that people had requested certain items of furniture for their bedrooms either to replace items or because these items were not in the bedrooms. The manager stated that this furniture had now been provided and further appropriate items of furniture were being requested. The previous inspection reports recommended that the home fully consult and take into account people’s choices and decisions in the refurbishment of the home and that evidence of this consultation should be documented. There was no documentary evidence that this was happening. The laundry facilities are located next to the kitchen area and are suitable for people’s needs. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not provide a sufficient staff team that has the skills, training and competence required to support peoples’ needs. EVIDENCE: The current management team consisted of the manager who divides her time with two other small homes managed by the same company and a deputy manager who has been allocated 8 hours to help the manager with the management of this and the two other homes. The manager stated that the care team currently consists of two and a half full-time equivalent support workers providing two staff on duty from 9:00am to 5:00pm and one from 5:00pm to 9:00pm. One staff is on sleep-in duty from 9:00pm to 9:00am. People received 1:1 support during the day however, the manager stated that they should receive 1:1 support from 8:00am to 9:00pm. The current staffing levels therefore impact on supporting people’s social and leisure activities and has already been raised in the report. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 21 To provide cover for staff vacancies, training, holidays and sickness the manager stated that support staff from other registered care homes, owned by the company, also worked at the home. In addition, the home has to use agency staff for at least four shifts a week. The issue of the size of the staff team and the use of agency staff had been raised in the previous inspection report. The manager, at the time, had stated that more staff had been and were being recruited to increase the size of the staff team. However, this issue has not been resolved and so the requirement was reiterated. The previous inspection report required the home to make sure that its staff team had the training, skills, knowledge and competence required to support peoples’ needs. The manager had a training schedule provided by the company that manages the home and included dates for Induction training, mental health, and care planning. They also provided a rolling Induction training programme. However, through discussions with the staff on duty, the manager and sampling training records it was found that a member of staff had no record of undertaking an Induction or training in Health and Safety, Moving and Handling, Abuse Awareness or Fire Training. Therefore, there was insufficient evidence to show that the home had met the requirement for ensuring its staff had the skills and knowledge required to support people living at the home and was reiterated. The manager had started to undertake staff supervision to identify the training needs of the staff team. Evidence was seen of the training that had been identified as needed and these events were being booked with the main company’s training team or an external provider. The manager also stated that they were going to carry out more in-house training sessions for the staff team. It is recommended that the home undertake an audit of staff training to establish the gaps in training and need for refresher training was required. Staff files had been previously sampled to assess whether all the required checks and documentation required through the recruitment process had been obtained. Files had been seen with completed application forms, references received and a contract of terms and conditions. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team and operational systems were in place to seek peoples’ views of the service and to maintain their health and safety. EVIDENCE: Since the last inspection report in December 2006 the manager, who had only recently been appointed at the time, had been asked to leave the service. The current manager had been in post for around 7 weeks. The manager had responsibility for two other small care homes all based within a short distance of each other. Due to the layout of the home the manager was not based at the home but visited every day. The current manager had several years of management experience including being a registered manager at another care home. They had experience in
28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 23 working with people with learning disabilities, autism and mental health issues. The manager had gained the Registered Managers Award in 2003. They were also developing their knowledge and skills through further study. They stated that they were aware of the need to apply to become the registered manager and had the relevant documents to complete. The manager must submit an application to become the registered manager of the home as required by the Care Homes Regulations 2001. The manager stated that they were aware of the issues and concerns regarding the home that have been identified through previous inspection reports. They stated that were supported to achieve these changes through her senior management but acknowledged that she had not had any formal supervision herself. It is recommended that the manager have access to regular and ongoing formal supervision to ensure that the managers own development needs and the progress in developing the service are clear and defined. The home has an established system of quality assurance undertaken by the company’s Quality Manager. This involves regular Regulation 26 visits to the home and undertaking ‘mock’ inspections to assess how the home is meeting the National Minimum Standards. The home also undertake an annual ‘Satisfaction Survey’ to gain the views of the people living at the home, relatives, carers and other relevant professionals. The manager was asked whether the monthly visits had identified the problems and concerns highlighted in this report. The manager stated that the reports she had seen had identified these issues. There were no copies of the visits maintained in the home. Copies of the Regulation 26 visits must be submitted to the CSCI to show that the home is addressing the issues raised in this inspection report. The manager stated that they had introduced a system where each month staff would spend time with each person to find out how they felt about the service and any concerns or problems they may have. Examples of these sessions with people were seen and showed that issues and concerns were being raised and dealt with. A fire log is maintained for visual checks and fire drills. A fire risk assessment had been reviewed. Up-to-date environmental risk assessments had been undertaken in relation to the health and safety of the home. Records for monitoring temperatures of the hot water and fridge/freezer were being maintained. 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 2 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 2 2 X X 2 X 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(2)(b) Requirement People’s support needs must be reviewed and record changes that are clearly reflected in the care plan and understood so that people receive the support they need. Timescale for action 01/07/07 2. YA9 13 (4) (b)(c) All areas of risk and hazards 01/07/07 associated with people’s aggressive behaviour must be identified and clear and detailed guidance provided to staff in how to manage these situations. People’s personal and healthcare needs and support must be clearly identified, recorded and reflected through the care planning process to make sure that they receive the support that they need. 01/07/07 3 YA18 YA19 15(1) 4. YA20 13(2) Staff must receive suitable 01/06/07 medication training to ensure that they are competent and that the medication administration system is safe. (Timescale of 01/11/06 and 01/02/06 was not met) 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 26 A clearly recorded auditing and monitoring system must be implemented to ensure the safe administration of medication. (The timescale of 01/11/06 and 01/02/07 was not met). 5 YA23 13 (6) 17(2) Schedule 4 The procedures and systems for 01/06/07 managing peoples’ finances must ensure that they accurately record and audit peoples’ personal finances in accordance to their own policy and procedures to protect people from possible abuse. An audit of all the refurbishment, 01/07/07 repairs and replacements required throughout the house must be undertaken. An action plan for carrying out this work must be provided to the CSCI with clear timescales for action. (Timescale of 01/11/06 and 27/02/07 was not met). A sufficient staff team must be in 01/07/07 place to provide the support and that people need at the times they need the support. (Timescale of 01/11/06 and 27/02/07 was not met). People must be supported by a staff team who have the necessary training, skills, knowledge and competence. (Timescale of 01/11/06 and 27/02/07 was not met). The manager must submit an application to become the registered manager of the home as required by the Care Homes Regulations 2001, to establish that they are ‘fit’ to manage the home.
DS0000021706.V334640.R01.S.doc 6. YA24 23 (1) 23 (2) (b) 7. YA32 18(1)(a) 8. YA35 18(1)(a) 01/07/07 9 YA37 9 (1) 01/07/07 28 Newland Street Version 5.2 Page 27 10 YA39 24 (2) Copies of the Regulation 26 visits 01/06/07 must be submitted to the CSCI to show that the home is addressing the issues raised in this inspection report. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that the home develop and implement a more person centred planning approach to how people identify their own needs, goals and the help they need to achieve them. It is recommended that all agency staff who have not worked with people before sign the guidance to show that they have read and understood the guidance. It is recommended that the home fully consult and take into account people’s choices and decisions in the refurbishment of the home. Evidence of this consultation should be documented. It is recommended that people’s medication regime is regularly reviewed to ensure they are still meeting the person’s needs. It is recommended that the guidance for administering PRN medication is reviewed to include greater information and detail in relation to when to use the relevant medication. 2 YA9 3 YA24 4 YA20 28 Newland Street DS0000021706.V334640.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North West Regional Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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